March 26, 2026
◎ Lee Po-Chang (Chair Professor, College of Public Health, Taipei Medical University, Taipei)

Recently, CT (computed tomography) scan services at major medical centers across northern and southern Taiwan have become severely congested, leaving hospital superintendents and radiology colleagues feeling deeply frustrated. Since the full implementation of the hospital-specific global budget system last April, government officials have taken pride in the increase in NHI reimbursement point values. However, they have failed to recognize the unintended consequences this change has brought—namely, growing dissatisfaction among both physicians and patients.

In practice, attending physicians are highly concerned about delays in diagnosis. As a result, they often have to privately request scheduling assistance or spend additional time arranging for patients to undergo examinations at partner hospitals. This sense of helplessness has significantly dampened younger physicians’ enthusiasm for working within the NHI system.

From a basic operational perspective, under hospital-specific global budgets, hospitals inevitably begin adjusting outpatient volumes and controlling the number of diagnostic tests and surgeries to avoid a “do more, lose more” scenario. This represents a fundamental shift from previous management models. Hospitals now aim to increase service volume only to the point that meets—but does not exceed—their individual budget caps. Financially, this appears successful: reimbursement point values rise, and the growth of claimed medical points is contained. However, the problem is that this system addresses only the management of supply, not the governance of demand.

Once individual hospital budgets are fixed, resources such as imaging, specialized tests, and surgical capacity effectively become limited quotas to be allocated. Yet under the current system, these resources are not prioritized based on medical necessity, but rather on patients’ healthcare-seeking behavior, clinical judgment, or even simple first-come, first-served timing. Previous data showed that as many as 127,000 cases annually (14% of total CT scans) involved patients who did not return to the original hospital within 30 days after undergoing imaging. Meanwhile, patients who genuinely require definitive diagnoses must wait in long queues or even be admitted to the hospital just to access examinations more quickly.

This creates a cascading effect. With ongoing nursing shortages and already limited bed capacity, hospitals are forced to use resources flexibly. Limited resources are repeatedly occupied but not effectively allocated. The result is not that “those in greatest need receive care first,” but rather that “those who manage to enter the system receive care first.” This is the core blind spot of the hospital-specific global budget system: it can control expenditures but cannot guide demand. Without mechanisms to manage demand, unnecessary medical services do not disappear—they continue to consume scarce resources. On the surface, the system appears to reduce costs, but in reality, it leads to misallocation of healthcare resources.

In addition, the concept of tiered healthcare delivery must be more effectively promoted. Its long-term failure to be fully implemented has resulted in large numbers of patients continuing to place their trust in medical centers with advanced equipment and renowned specialists. Many conditions that could be managed at regional hospitals, district hospitals, or primary care clinics are instead concentrated in high-level medical centers, further straining limited resources. This is not merely a matter of patient behavior, but a failure of the system to provide appropriate guidance.

Therefore, if NHI reform remains focused solely on adjusting global budgets or recalculating reimbursement points, it will not solve the underlying problems. What must be addressed is how to prioritize care based on medical necessity and reduce the occupation of resources by unnecessary medical services. One long-avoided but unavoidable tool is user-pay cost-sharing. Particularly for high-frequency services such as laboratory tests and imaging, the absence of price signals naturally leads to unlimited demand expansion. Moderate cost-sharing does not undermine equity; rather, it encourages shared decision-making between physicians and patients regarding healthcare choices. It also allows healthcare professionals to practice based on expertise, rather than defensive medicine, and to regain a sense of professional fulfillment.

If the system relies solely on waiting lines to allocate resources, those ultimately excluded will not be unnecessary services, but patients who lack the ability to wait. In the end, the hospital-specific global budget system risks becoming a mechanism that appears to control costs but actually misallocates resources—rapidly depleting limited capacity through indiscriminate use, while patients in genuine need bear the consequences of delayed care.

Original source:
https://udn.com/news/story/7339/9403453